Maternal Exam 3
A primigravida is admitted in early labor. The nurse notices on the prenatal record that the position of the fetus is left occiput posterior. Because of this information, the nurse can anticipate
increased back pain with labor
A nurse suspects cephalopelvic disproportion in a client who is having a difficult labor. For which test should the nurse prepare the client?
Ultrasound
After delivery of an infant with shoulder dystocia, the patient has a postpartum hemorrhage. The nurse notes that the bleeding spurts and clots. What could be the cause of this patient's bleeding?
Uterine atony
A woman with an epidural has been pushing for the past 2 hours with very little progression. An appropriate nursing action at this point is to
assess for a full bladder
A pregnant patient walks into the birthing center complaining of contractions. After getting her to bed, the first thing the nurse should do is
assess the fetal heart rate
To obtain an accurate blood pressure of a woman in labor, the nurse should assess the blood pressure
between contractions, with the woman lying on her side
In caring for a low-risk woman in the active phase of labor, the nurse realizes the assessment of fetal well-being should occur
every 30 minutes
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be
hypotension
After birth, the woman complains of chills. The first intervention by the nurse should be to
place a warm blanket on the woman
A fetus is in the posterior position. The woman is complaining of back labor and the labor is prolonged. The nurse can best assist the mother with this problem by
placing her in a hands and knees position
The term that describes a labor lasting 3 hours or less is ____________.
precipitous labor
The nurse should tell a primigravida that the definitive sign indicating labor has begun is
progressive uterine contractions
Misoprostol (Cytotec), 50 mcg, has been ordered for a woman to assist with the ripening of the cervix. The nurse's action should be to
question the dosage amount
A woman must have general anesthesia for a planned cesarean birth because of a previous back surgery. The nurse should therefore expect to administer
ranitidine (Zantac)
During a vaginal exam, the physician stimulates the fetal scalp. The fetal heart rate accelerated from 140 to 155 bpm for about 30 seconds. The nurse should
record this fetal reaction.
As full term nears, the cervix softens because of the effects of the hormone relaxin and increased water content. This cervical change is termed ____________________.
ripening
A woman came in for a prenatal check up on March 15. She tells the nurse that her last normal menstrual period was June 2. The nurse is aware that she will be scheduled for
testing to determine fetal well-being
Fluctuations in the baseline FHR that cause the printed line to have an irregular rather than a smooth appearance is termed ___________________.
variability
While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action?
Asking the client when she last changed the perineal pad
The nurse is assisting with a normal vaginal delivery. The placenta has been delivered, and the patient is receiving oxytocin via IV access. What should the nurse do?
Assess the status of the fundus with gentle massage.
Which one(s) of the following are important points when teaching a patient the proper method for pushing during the second stage of labor? (Select all that apply.)
Begin and end by taking a deep breath and exhaling. Push for 4 to 6 seconds at a time.
How should a nurse cirect care for a client in the transition phase of the first stage of labor?
Helping the client maintain control
When pressure is applied to the fetal chin through the perineum at the same time pressure is applied to the occiput of the fetal head, it is termed the _______________.
Ritgen maneuver
While observing a mother visiting her preterm son in the neonatal intensive care nursery, the nurse notes that she has not yet begun the bonding process. Which statement by the mother supports the nurse's conclusion?
"It's such a tiny baby."
The nurse is preparing a 20-year-old patient who is gravida 2, para 0 at 41 weeks' gestation for a forceps delivery to assist in rotation and delivery of the fetal head. While placing the feet in footrests, the patient states, "I'm really in a lot of pain!" How should the nurse respond?
"The anesthesia provider will make sure you're comfortable before the doctor applies the forceps."
The nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. Which positive sign of pregnancy should the nurse evaluate in this client?
Audible fetal heartbeat
After a delivery that involves shoulder dystocia, the nurse should assess the newborn for which complication?
Brachial plexus injury
Which one(s) of the following are considered abnormal (Category III) heart rate patterns? (Select all that apply.)
Bradycardia Absent variability Recurrent variable decelerations
Which one of the following measures will help prevent complications from an episiotomy?
Cold applications after birth
Which statements regarding the involution process are correct? SATA.
Involution begins immediately after expulsion of the placenta. Involution progresses rapidly during the next few days after birth. Involution is the return of the uterus to a non pregnant state after birth.
When doing a vaginal exam, the nurse notes a triangular-shaped depression toward the mother's left side and pointing up toward her abdomen. The nurse can record the fetal position as
LOA
Which one(s) of the following actions should be included in nursing care during labor? (Select all that apply.)
Offer ice chips in small amounts to relieve a dry mouth. Monitor for a full bladder because the woman may have a decreased sensation of the urge to void. Keep the woman in a side-lying position to prevent supine hypotension. Monitor the fetal heart rate for changes from normal.
Which one(s) of the following are used to assist with the cervical ripening process prior to induction of labor? (Select all that apply.)
Prostaglandin Misoprostol(Cytotec) Laminaria tents
The midwife has just examined a labor patient and states that she is 10 cm dilated. The nurse is aware that this patient is in which stage of labor?
Second
The circulating nurse receives a hand-off report from the labor nurse and assists the patient, who needs regional anesthesia, to the OR table. What is the most appropriate action for the circulating nurse?
Stay by the patient's side, call for a time out verification, and position the patient for anesthesia induction.
During the active stage of labor the woman is using a rapid "pant-blow" breathing pattern. She starts to complain of feeling dizzy and has some numbness in her fingers. The nurse's next action should be to
have the woman breathe into a paper bag
A woman who is 27 weeks pregnant calls the clinic and complains of constant low backache. The nurse should
have the woman come in to be evaluated.
What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful?
"I will apply warm packs and massage my breasts before each feeding."
The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action?
Change the maternal position
Which one(s) of the following are considered theories about the onset of labor? (Select all that apply.)
Changes in the relative effects of estrogen and progesterone An increase in prostaglandins Stretching and irritation of the uterus and cervix
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next?
Changing the client's position
During the labor process, the patient's membranes rupture. Select all the assessments that are necessary for the nurse to carry out at this time. (Select all that apply.)
Color of amniotic fluid Odor of amniotic fluid Fetal heart rate Time the membranes ruptured
The nurse is assessing a patient during the immediate postpartum period following a vaginal delivery and finds that the uterus is boggy and displaced to the right. Which action should the nurse perform?
Encourage the patient to void or confirm orders for bladder catheterization if needed.
Which one of the following laboring women is at highest risk for a prolapsed cord? All the women have intact membranes and are cephalic presentations.
Gravida 1, station ?2-2, cervix 3 cm, and 50% effaced
All of the following women in labor are requesting pain medication. To which one should the nurse administer an opioid analgesic first?
Gravida 2, 6 cm dilated, 100% effaced, rocks back and forth in bed with each contraction
What is the priority nursing intervention during the admission of a primigravida in labor?
Monitoring the fetal heart rate
A patient has been given oxytocin at 5 milliunits/min for the past hour to augment labor. The patient's contractions are occurring every 1 to 3 minutes. The student nurse asks whether tachysystole is present. What should the nurse offer as the definition of tachysystole?
More than 5 contractions in 10 minutes averaged over a 30-minute window
A nurse in the birthing suite has just admitted four clients. Which client should the nurse anticipate may require a cesarean birth?
Multipara with a shoulder presentation
When admitting a patient for induction of labor, the nurse will question the procedure if which one of the following observations is on the patient's prenatal record?
Placenta previa
A patient who experienced shoulder dystocia has delivered. During the immediate postpartum phase, the nurse should assess the patient for which complication?
Postpartum hemorrhage
An intravenous access is started in most labor patients because of which one(s) of the following? (Select all that apply.)
To have quick access if drugs are needed To provide fluids to prevent dehydration In case an epidural block is administered
During contractions the fetus has mechanisms in place to protect it from the decrease in blood flow. Those mechanisms include
a high cardiac output level
On review of a fetal monitor tracing, the nurse notes that for several contractions the FHR decelerates as a contraction begins and returns to baseline just before it ends. The nurse should
describe the finding in the notes
Which one(s) of these conditions might cause late decelerations in the fetal heart rate? (Select all that apply.)
Maternal hypotension Excessive uterine activity Maternal hypertension
A patient is being discharged, having been diagnosed with false labor. The nursing diagnosis for her is Deficient Knowledge: characteristics of true labor. An appropriate expected outcome for this diagnosis is that the
Patient will describe reasons for returning to the hospital for evaluation
While caring for a client in labor, the nurse notes that during a contraction there is a 15-beat-per-minute acceleration of the fetal heart rate above the baseline. What is the nurse's most appropriate action at his time?
Record the fetal response to contractions and continue to monitor the heart rate
Variability can be reduced by which one(s) of the following factors? (Select all that apply.)
Sleep Narcotics Fetal anomalies that affect the central nervous system
A multigravida is in active labor after the initiation of induction 12 hours ago. Which event should alert the nurse to an increased risk of shoulder dystocia?
The mother experienced shoulder dystocia with her previous delivery.
If the head retracts against the perineum after the birth, it is commonly referred to as the __________________.
turtle sign
A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How should the nurse respond?
"Your diaphragm has been displaced upward."
A patient who is a gravida 5 para 4 at 38 weeks' gestation arrives at the labor and delivery unit in active labor. The nurse performs a sterile vaginal examination and determines that the patient's cervix is dilated to 8 cm. The patient has no IV access at the time of delivery. The nurse recognizes that the patient has an increased risk of postpartum hemorrhage because of multiparity. Which dose of oxytocin is most commonly prescribed to be administered intramuscularly after delivery of the placenta to prevent postpartum hemorrhage?
10 units of oxytocin
A new nurse is asking an experienced nurse about interpreting a Category III FHR tracing. The experienced nurse tells the new nurse that a Category III FHR tracing may include which characteristic?
Absent FHR variability
While caring for a patient in active labor at 39 weeks' gestation, the nurse interprets the FHR tracing as a Category III. After discussion regarding the FHR tracing, the resident and attending practitioner on duty determine that the FHR tracing is a Category II. The nurse still interprets the FHR tracing as a Category III. What would be an appropriate next action by the nurse?
Activate the organization's chain of command.
The nurse is admitting a patient at 40 weeks' gestation for induction of labor. The nurse knows that in most cases, contraindications for labor induction are the same as the contraindications for vaginal birth. What contraindication would the nurse need to report to the practitioner?
Active genital herpes
A primigravida who is laboring at 39 weeks' gestation has a prolonged deceleration (9 minutes). The obstetrician calls for an emergency cesarean section. An internal fetal electrode is on the fetal head to monitor the FHR. The nurse attempts to remove the internal lead but is unsuccessful. What is the nurse's next action in this emergency?
Cut the lead wire as close as possible to the Introitus.
The nurse is caring for a client in active labor at a birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. In which stage of labor is this client?
First
During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's priority intervention?
Helping the client turn to the side lying position
The postpartum nurse has just received report on a new patient who had a cesarean delivery 2 hours earlier. The nurse performs an initial postpartum assessment and then a fundal assessment, which reveal that the uterus is boggy and 3 cm above the umbilicus and midline. Bleeding is scant rubra. Which nursing response is appropriate?
Perform fundal massage until the fundus is firm
The nurse has completed a fundal assessment after a vaginal delivery. Although the patient has just voided, her uterus remains boggy at the umbilicus and midline. What should the nurse do?
Perform fundal massage, cupping one hand over the fundus and supporting the uterus at the symphysis pubis with the other hand.
Which forceps are used to assist with delivery of the head in a breech birth?
Piper forceps
To help prevent the patient from developing deep vein thrombosis as a result of surgery, the nurse should take which preventive action in the OR?
Place a sequential compression device on the patient's lower extremities.
A patient undergoing an emergency cesarean section has just been placed on the OR table. What does the circulating nurse do to ensure the safety of the patient?
Place safety straps on her upper and lower extremities.
A nurse is caring for a patient who has been receiving an oxytocin infusion for labor induction. The infusion was initiated approximately 8 hours ago and is currently infusing at 20 milliunits/min. While assessing the patient, the nurse observes a Category I FHR tracing with a contraction pattern of six contractions in 10 minutes averaged over 30 minutes. Which of these nursing interventions should come first?
Place the patient in a lateral position
A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one indication that the client should refrain from intercourse during pregnancy?
Premature rupture of membranes
A client in labor is admitted with a suspected breech presentation. Which occurrence should the nurse be prepared for?
Prolapsed cord
A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time?
Promotion of maternal and fetal well being during labor
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be?
Provide the client with comfort measures used for women in labor.
The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions?
Push with her glottis open
While caring for a patient who is gravida 2 para 1 being induced for oligohydramnios, the nurse notices a pattern of recurrent abrupt decelerations down to 70 bpm with contractions lasting for 1 minute. What is an appropriate initial intervention in this case?
Repositioning the patient
A 22-year-old patient who is gravida 2, para 1 at 40 weeks' gestation has pushed the baby to a +3 station over 2 hours but is now exhausted. The physician offers to help the patient deliver with forceps, and the patient agrees. What is the most immediate risk?
Shoulder dystocia
A patient who is gravida 3, para 2 delivers precipitously while in bed. The placenta is expelled spontaneously a few minutes after the delivery. The practitioner has been notified and is en route. The nurse notices that the patient is still bleeding vaginally and performs a fundal assessment. The fundus is firm at the umbilicus and midline. Which action should the nurse take?
Suspect a vaginal laceration and prepare for the practitioner's inspection.
Before forceps application, the nurse should notify the physician of which contraindications?
Suspected bleeding disorder, fetal bone demineralization condition, unengaged head position
What is the most common cause of postpartum hemorrhage?
Uterine atony
The patient is admitted in early labor. Her support person tells the nurse that the contractions have the following pattern: started 1232, ended 1233; started 1235, ended 1236; started 1239, ended 1240; started 1243, ended 1244. From this information, the nurse determines that the frequency of the contractions is
every 3 to 4 mins
A client is scheduled for a nonstress test in the 37th week of gestation. The nurse explains the procedure. Which statement demonstrates that the client understands the teaching?
"If the heart reacts well, my baby should do ok when I give birth."
A laboring patient asks the nurse why catheterization is needed before a forceps-assisted delivery. How should the nurse respond?
"If your bladder is full, there is less room in the birth canal for your baby."
A 33-year-old multipara at 41 weeks' gestation delivered a vigorous baby girl with Apgar scores of 9/9. A forceps delivery was required. The newborn was dried, assessed, and placed in the mother's arms. The mother asks the nurse why the baby's cheek has a red mark and a bruise. How should the nurse reply?
"The pressure of the forceps on the baby's delicate skin can cause minor redness or bruising that usually resolves without treatment. We will continue to observe your baby for any complications."
An amniotomy is performed to stimulate labor in a client at 42-weeks' gestation. Place the nursing care actions in their order of priority.
1. Inspect the perineum for umbilical cord prolapse 2. Checking the fetal heart rate tracings 3. Assessing the characteristics of the amniotic fluid 4. Evaluating the client for sings of an infection
After birth, the nurse assesses the newborn. The heart rate is 90 bpm, the body is flexed, there is vigorous movement, the newborn is actively crying when stimulated, and has bluish coloration in the feet and hands. The proper Apgar score for this newborn should be
8
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing?
Abruptio placentae
A pregnant client arrives on the birthing unit from the emergency department with frank blood running down both legs and a reported low blood pressure. What is the priority nursing intervention?
Assessing fetal heart tones
A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate?
C section
After several unsuccessful attempts to deliver the baby of a 32-year-old primigravida at 40 weeks' gestation using the vacuum extractor, the physician states he will attempt to deliver the baby with forceps. The nurse knows that the sequential use of a vacuum extractor and forceps is associated with increased rates of which neonatal complication?
Cerebral hemorrhage
A 20-year-old woman is admitted to the labor and delivery unit after reporting that she is experiencing severe contractions. She is 38 weeks +2 days' gestation. External fetal monitoring has been initiated. During the assessment the nurse notes that the woman is sweating profusely, has dilated pupils and irregular respirations, is hypertensive, and continues to complain of very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. What should the nurse suspect?
Cocaine abuse
A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect?
Complete abruptio placentae
When administering oxytocin for induction of labor with a low-dose or high-dose administration protocol, what is the usual frequency for incremental increases?
Every 15 to 40 mins
The physician is attempting an outlet forceps delivery. Which clinical observation would be consistent with this classification of delivery?
Fetal scalp is visible at the Introitus without separating the labia.
Which one of the following findings during the fourth stage would require immediate interventions by the nurse?
Fundus firm, deviated to the right, with slight distention over the symphysis pubis
The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client for?
Hemorrhage
While a multiparous client is in active labor, her membranes rupture spontaneously. The nurse notes a loop of umbilical cord protruding from her vagina. What is the priority nursing action at this time?
Holding the presenting part away from the cord
During a cesarean delivery, bright red blood appears in the drainage bag of the indwelling urinary catheter. What should the circulating nurse do?
Immediately inform the physician and anesthesia provider of the findings.
During a forceps application for delivery, a primigravida is pushing with a contraction to assist the delivery. The nurse looks at the fetal monitor and notices that the FHR has been at 60 bpm for 2 minutes. What should the nurse do next?
Immediately notify the physician of the FHR
How does childbirth pain differs from other types of pain? (Select all that apply.)
It is a normal process. There is prep time. It is self limiting. It is intermittent.
As the nurse is admitting a woman in labor, she notices that the woman is happy and excited that she is in labor. The contractions are 5 minutes apart, lasting 30 to 35 seconds. The nurse can anticipate that the patient is in which phase of labor?
Latent
The nurse is preparing for a vaginal delivery by a multipara who has a history of shoulder dystocia. The nurse explains to the student nurse that one of the maneuvers used for shoulder dystocia involves having the patient flex her hips while pulling her thighs straight up to her abdomen to help rotate the symphysis pubis anteriorly and dislodge the fetus's anterior shoulder. What is the name of this maneuver?
McRoberts maneuver
The nurse admits a patient to the labor and delivery unit for induction of labor. The patient is at 37 weeks' gestation and has preeclampsia. The last ultrasound showed fetal growth restriction. The patient's current vital signs are blood pressure 167/101 mm Hg, pulse 96 bpm, respirations 20 breaths/min, and temperature 36.4°C (97.5°F). The patient denies feeling contractions or having pain. The practitioner has written orders to begin labor induction with oxytocin. What should the nurse do to establish maternal and fetal well-being upon admission?
Monitor the FHR and contraction patterns electronically for 20 to 30 minutes.
To ensure adequate fetal oxygenation, which one(s) of the following are needed? (Select all that apply.)
Normal maternal blood flow and volume to the placenta Normal oxygen saturation in maternal blood Adequate exchange of oxygen and carbon dioxide in the placenta Normal fetal circulatory and oxygen-carrying functions
Following a forceps delivery, the nurse assesses the patient's fundus. It is firm, but the patient continues to have a slow steady trickle of bright red bleeding. What should the nurse do?
Notify the physician the evaluate the patient for lacerations.
While admitting a patient who is at 40 weeks' gestation, the nurse observes an FHR of 165 bpm with recurrent decelerations. The decelerations show a symmetric gradual decrease in the FHR, which begins at the peak of each contraction and ends 10 to 15 seconds after the contraction has returned to resting baseline. What should the nurse do in this situation?
Position the patient on the left side for improved uteroplacental circulation.
Relaxation of the mother during labor is important for several reasons. Which one(s) of the following are reasons that promoting relaxation is important? (Select all that apply.)
Promotes uterine blood flow Improves fetal oxygenation Promotes efficient uterine contractions Reduces tension that increases pain
A laboring patient who is about to undergo a cesarean delivery has a large amount of lower abdominal and pubic hair. The FHR is approximately 90 bpm with minimal variability. The amount of bloody show is moderate. What is the most appropriate action?
Remove the hair at the surgical site selectively with electric or battery operated clippers or a depilatory method.
A patient requiring an emergency cesarean section has a metal tongue ball in place. What should the nurse do before surgery?
Remove the metal tongue ball before the surgery.
A patient is in active labor and is being continuously monitored with a fetal monitor. The patient's labor has been normal to this point. The patient's membranes ruptured 1 hour ago, and the fluid was clear. The FHR baseline is 125 bpm. Contractions are occurring every 3 minutes and lasting 60 seconds, and are of moderate intensity with a soft resting tone. On entering the room, the nurse sees the patient lying supine and notices that there has been abrupt slowing in the FHR to 90 bpm during the last two contractions, each episode lasting 30 seconds or less. The patient complains of breathlessness and becomes pale and diaphoretic. What is the most appropriate nursing response?
Reposition the patient, check bp, and continue to monitor the FHR pattern.
A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during labor?
Scheduling pain medication at regular intervals.
A client with a history of a congenital heart defect is admitted to the birthing unit in early labor. Which position does the nurse encourage the client to assume?
Semi Fowlers
A client at 42 weeks' gestation is scheduled for induction of labor. The nurse begins the induction with a piggyback infusion of 15 units of oxytocin. Which clinical finding requires the nurse to discontinue the oxytocin infusion?
Several late fetal heart rate decelerations that return to baseline after the contraction is over
The nurse removed the dinoprostone an hour ago from the cervix of a patient being induced for gestational diabetes at 39 weeks' gestation. The patient is having strong contractions lasting 60 to 90 seconds every 3 minutes. The nurse is preparing to start administration of oxytocin. What possible complication could occur?
Tachysystole
What is the usual cause of shoulder dystocia at delivery?
The anterior shoulder becomes lodged behind the maternal symphysis pubis after delivery of the head.
The nurse is assessing the fundus of a patient who delivered vaginally 2 days ago. The nurse knows that typically the fundus descends 1 to 2 cm every 24 hours. How is the height of the fundus described in relation to the umbilicus?
The height of the uterine fundus is described in centimeters in relation to the umbilicus.
An emergency cesarean section has just been ordered because of a Category III FHR tracing. The anesthesia provider asks the nurse to give the patient a bolus of lactated Ringers solution before surgery. What is the rationale for this action?
To protect the patient in case she has excessive bleeding after delivery
The incoming nurse is receiving a report regarding a laboring patient whose cervix is 7 cm dilated, who has a fetal spiral electrode in place, and who is receiving IV oxytocin for augmentation of labor. The reporting nurse states that the FHR baseline is 150 bpm with moderate variability, no decelerations are present, and episodic accelerations are occurring. The patient received an epidural bolus approximately 10 minutes ago. The incoming nurse enters the patient's room to complete an initial assessment and sees that the FHR has been 80 bpm for the last 3 minutes and that variability is minimal to absent. What should the incoming nurse do FIRST?
Turn the patient to the left side, stop the oxytocin infusion, and assess maternal vital signs.
The nurse is caring for a multigravida at 41 weeks' gestation with a history of gestational diabetes. Her cervix is fully dilated, and she is delivering. As the head is delivered, the nurse notices that it immediately retracts against the perineum. What is this condition?
Turtle sign
The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations?
Uteroplacental insufficiency
Which one of the following findings meets the criteria of a Category I FHR pattern?
Variability averages between 6 and 25 bpm.
While caring for a woman who is 10 cm dilated, is pushing, but is fatigued and her pushing efforts are ineffective, the nurse notices that the fetal heart rate has dropped to 85 bpm. The station is +3. The nurse can anticipate
a low operative vaginal birth
A woman who has been admitted for preterm labor is started on terbutaline (Brethine) to decrease uterine irritability. Within 24 hours, the contractions have stopped and the woman is resting comfortably. During vital sign assessment the nurse records a blood pressure reading of 125/74 mm Hg, pulse, 95 bpm, and respirations, 12 breaths per minute. The blood pressure and respirations are within limits of previous readings, but the pulse has increased from a previous reading of 74 to 80 bpm. The nurse's next action should be to
assess the fetal heart rate
A gravida 1 woman who is 39 weeks of gestation and has had no prenatal care is admitted into the labor unit in early labor. During the assessment, the nurse finds the fetal heart tones in the right upper quadrant. The nurse should anticipate
c section
A woman is admitted in early labor. The prenatal record states that the fetus is in a transverse lie with a shoulder presentation. The nurse can anticipate a
c section
A woman delivered a baby boy 30 minutes ago. The labor and birth were uneventful. The nurse is assessing the woman's vital signs when the woman suddenly complains of chest pain and difficulty breathing. The vital signs show a decreased blood pressure and a slightly increased pulse. The nurse's next action should be to
call for assistance
The technique of delaying pushing until the reflex urge to push occurs may be called _____________________.
delayed pushing, laboring down, rest and descend, or passive pushing
The laboring woman may rub her abdomen during a contraction to counteract discomfort. This is called ______________________.
effleurage
A woman admitted with preterm labor is started on nifedipine (Procardia) to reduce uterine muscle contractions. The nurse should include in this woman's care plan a nursing diagnosis of
risk for injury
A client's membranes rupture, and the nurse immediately detects the presence of a prolapsed umbilical cord. The nurse alerts another nurse, who calls the primary healthcare provider. Place the following nursing interventions in the order in which they should be performed.
1. Moving the presenting part off the cord 2. Placing the client in the Trendelenburg position 3. Administering oxygen by facemask 4. Checking the fetal heart rate
Which one of the following women can the nurse anticipate having difficulty dealing with labor pain?
A woman having her second baby; the first child was in a posterior position and the labor lasted 18 hours
The nurse assesses the fundus of a patient who delivered a full-term newborn 3 hours ago and is now gravida 2, para 2. The nurse finds the uterus to be boggy on palpation. The nurse massages the patient's uterus and attempts to express any clots; however, bleeding is minimal, and no clots are expressed. The nurse also determines that the patient's bladder is empty. What should be the nurse's next course of action?
Assess vitals and notify the practitioner
A 36-year-old woman, G1 P0, is admitted to the labor and delivery unit for oxytocin induction. She is at 40 weeks' gestation. Which condition is a contraindication to the use of oxytocin induction?
Active genital herpes infection
The nurse has received an order from the practitioner to begin labor augmentation with IV oxytocin on a patient at 39 weeks' gestation. The pharmacy notifies the nurse that no premixed bags are available and that the premixed solution will arrive on the unit in approximately 30 minutes. What is the most appropriate nursing action?
Alert the practitioner that the oxytocin infusion is being held until the pharmacy delivers the solution to the unit.
The physician has explained to the patient that her baby needs to be delivered by an emergency cesarean delivery. The patient is crying because she wanted to deliver her baby "naturally." What is the most appropriate nursing action?
Allow the patient to express her feelings and address them in depth as time permits.
A multigravida at 37 weeks of gestation is admitted to the labor room. She has contractions every 3 to 4 minutes lasting 40 to 50 seconds and no history of clear fluid leakage from the vagina, but complains of bright red bleeding for the past hour. The fetal heart rate is 145 beats/minute (bpm). What should be the nurse's next intervention?
Call the physician promptly
Which one(s) of the following would be an indication for a cesarean birth? (Select all that apply.)
Cephalopelvic disproportion Active genital herpes Persistent nonreassuring FHR patters
A client who is in labor is admitted 30 hours after her membranes ruptured. Which condition is this client at increased risk for?
Chorioamnionitis
The nurse is caring for a low-risk primipara at 40 weeks' gestation and in active labor. Per the practitioner's order and the patient's request, the nurse has been monitoring the fetal heart rate by IA. The patient is now 7 cm dilated, 100% effaced, and at +1 station. During auscultation, the nurse hears an abrupt deceleration of the FHR down to 60 bpm that lasts for 1 minute before returning to baseline. What should be the nurse's next action?
Connect the patient to an EFM
Labor pain management may include which one(s) of the following interventions? (Select all that apply.)
Cool, damp washcloths on the face and neck Decreasing bright lights in the room Keeping the woman clean and dry Administering pain medication as ordered
The practitioner ruptures a laboring patient's membranes and inserts a fetal spiral electrode because the nurse is unable to obtain FHR data by the external method. The FHR baseline is 130 bpm with moderate variability. The patient is having contractions every 4 minutes, each lasting 50 seconds. One hour later, the nurse notices that the FHR baseline is 145 bpm with minimal variability. The nurse observes smooth, gradual decelerations to 135 bpm occurring with more than 50% of the contractions. What should the nurse do before appropriate clinical interventions are initiated?
Determine the onset and end of each deceleration in relation to the onset and end of the contraction.
Which physical factors contribute to pain during labor and birth? (Select all that apply.)
Tissue ischemia Cervical dilation Distention of the vagina and perineum
A vaginal birth after cesarean is often abbreviated __________.
VBAC
A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe which one of the following?
bloody show
Research has found that bed rest as an intervention for preventing preterm labor can result in
bone demineralization, with calcium loss
A 39-week primigravida calls the birthing center and tells the nurse she has contractions that are 10 to 15 minutes apart and had a small gush of fluid about 1 hour ago. The nurse should tell her to
come to the birthing center now.
The midwife records that the patient's cervix is "100%, 5 cm." The nurse understands that the patient's cervix is
completely effaced and half dilated
A nurse is reviewing the charts of antepartal patients. A 28-week-gestation woman's fetal fibronectin report has returned, with negative results. The nurse should
document this report
Immediately following an amniotomy to observe for complications, the nurse must assess the
fetal heart rate
During birth, shoulder dystocia was diagnosed. After the birth and the newborn has been stabilized, it is important for the nurse to assess the newborn for
fractured clavicles
During the latent phase of labor, the nurse suggests that the woman play cards with her husband. The nurse is aware that this will help the woman deal with the pain of contractions. The effectiveness of this technique is explained by
gate control theory
The nurse notices on the admission record that the fetus is in a cephalic military presentation. The nurse realizes that the fetus
has the head in the birth canal first, but the head is not flexed
A patient requires an emergency cesarean delivery because of a prolapsed umbilical cord. The pediatrician and a nursery nurse are present for the delivery. When the newborn is delivered, resuscitation efforts are prolonged. What should the circulating nurse do?
Call for additional help and then assist as able.
Which type of uterine rupture may go undiagnosed during labor and the postpartum period?
Dehiscence
A patient at 41 weeks' gestation arrives on the unit for labor induction. The practitioner has ordered continuous electronic monitoring, but the patient requests IA for the early part of labor. The nurse has no other patients to care for at this time. The organization's practice allows for IA if 1:1 nursing staff is available. What should the nurse do next?
Evaluate the patient's understanding of the monitoring methods and notify the practitioner.
Why is a cleansing breath at the beginning and end of contractions important? (Select all that apply.)
Helps the woman release tension Provides oxygen to reduce myometrial hypoxia
A woman is receiving magnesium sulfate intravenously to control preterm labor. She is at the maximum dose and the contractions have slowed to eight/hr. The nurse is assessing the woman's vital signs every hour. In addition to blood pressure, pulse, and respirations, what other assessments should be carried out hourly?
Lung sounds
A nurse caring for a patient in labor calls a colleague for assistance because of shoulder dystocia. The assisting nurse arriving in the room knows that the best chance for successful resolution of shoulder dystocia includes the combination of which two interventions?
McRoberts maneuver and suprapubic pressure
A primigravida has just delivered at term, and the nurse is palpating her fundus. Where should the nurse expect to find the patient's fundus?
Midline between the umbilicus and the symphysis pubis
A patient is in active labor with spontaneous contractions occurring every 2½ minutes and lasting 90 to 100 seconds. The patient is being monitored by external electronic monitoring. The baseline FHR is 135 bpm with moderate variability. While assessing the FHR, the nurse notices a pattern of uniform decelerations that have an abrupt onset with a nadir down to 90 bpm for 30 seconds. What characteristic of this fetal heart rate tracing is indicative of fetal well-being?
Moderate variability
After assisting a new mother with breastfeeding, the student nurse asks an experienced nurse if breastfeeding affects the uterus. What is the best response by the nurse?
The secretion of oxytocin with breastfeeding causes strong contractions and a decrease in the size of the uterus.
During each contraction, the nurse notices that the woman stops talking and stares at a picture on the wall. The nurse realizes that the woman is using the picture as a
focal point
During active labor, the woman complains about tingling in her hands. The nurse's next action should be to
help the woman slow down her breathing and breathe into her cupped hands.
A woman had premature rupture of the membranes at 37 weeks of gestation. She went into labor within 10 hours and delivered a 7 lb, 12 oz boy after a 12-hour labor. In planning care for the newborn, it is important to monitor him for
infections
A primigravida is in the latent phase of labor and is at low risk for complications of labor. She asks the nurse if she may walk for a few minutes. The nurse is aware that this is (is not) possible because
intermittent auscultation of fetal heart rate is appropriate for her
A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the nurse to intervene?
lack of knee jerk reflex
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of oxytocin (Pitocin). The woman is in a side-lying position and her vital signs are stable and within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's immediate action would be to
stop the oxytocin.
During labor, the nurse notices that the woman's support partner touches her lightly during contractions. When the woman is touched, she relaxes her muscles. The nurse realizes that the couple is using the technique of
touch relaxation
The nurse is preparing to auscultate the fetal heart rate using a Doppler transducer. When performing the Leopold maneuver, the nurse felt the buttocks near the fundus and the back along the left side of the mother. The best position for the Doppler would be in the mother's
left lower quadrant
A patient is receiving oxytocin for induction of labor with an initial infusion rate of 2 milliunits/min and a titration rate of 2 milliunits/min every 30 minutes. The FHR tracing indicates a Category I pattern with uterine tachysystole. Despite implementation of interventions that include repositioning the patient to a lateral position and administering an IV fluid bolus, the tachysystole continues. A Category II FHR tracing is then observed. The nurse discontinues the oxytocin, which was infusing at 12 milliunits/min. After the infusion has been discontinued for 20 minutes, the tachysystole has resolved and the fetal monitor tracing indicates adequate fetal oxygenation. At which rate should the nurse restart the oxytocin infusion?
6 milliunits/min
A patient at 38 weeks' gestation with a history of preeclampsia is being induced. The patient received a dose of misoprostol 3 hours ago. The practitioner places an order for the nurse to start IV oxytocin now. What is the nurse's response?
Notify the practitioner of when the dose of misoprostol was given.
During the delivery by a multipara at 41 weeks' gestation, shoulder dystocia occurs, and the practitioner instructs the nurse to apply pressure above the pubic bone over the fetal anterior shoulder using a downward and lateral motion on the posterior aspect of the fetal shoulder. Which maneuver is the practitioner describing?
Suprapubic pressure
A woman has reached 10 cm and is attempting to push. She had an epidural and is unable to feel the urge to push. The nurse can best assist her by
letting her labor down, that is delaying pushing until she feels the reflexive urge to push.
Firm contractions that occur every 3 minutes and last 100 seconds may reduce fetal oxygen supply because they
limit the time for oxygen exchange in the placenta
A woman who is about 37 weeks' gestation tells the nurse that for some reason this morning she can breathe easier. The nurse can best explain this as being a concern, and the fetus needs to be assessed.
normal change because of the fetus's dropping down into the pelvis region, relieving the pressure on her diaphragm.
After a planned cesarean section, the woman is being admitted back to the postpartum unit. The nurse notices that the patient is rubbing her nose and eyes continually. Being aware that the woman has been given epidural opioids, the nurse's next action should be to
offer the woman some medication to relieve the itching
A woman is receiving oxytocin for labor induction. The nurse notices the woman is having contractions every 2 minutes lasting for 100 seconds. The fetal heart rate is 120 to 130 bpm, with moderate variability. The nurse's next action should be to
turn off the oxytocin
On admission to the labor suite, a woman begins to cry out loudly, "Lord help me, I am going to die." She repeats this phrase loudly with each contraction. The nurse's best response would be to
understand that this may be a cultural mannerism and accept her individual response to labor
A 39-week-gestation gravida 1 is 6 cm dilated. Membranes are intact. The labor contractions have decreased in intensity, and she has not dilated in the past 2 hours. A diagnosis of hypotonic dysfunctional labor has been made. The nurse can anticipate which of the following actions?
Amniotomy
A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is the best gauge for the client to use?
Amount of blood lost in relation to usual menstrual flow.
Which one of the following characteristics is associated with false labor contractions?
Decrease in intensity with ambulation
A nurse is assigned to document the time of each procedure during a delivery in which a shoulder dystocia has occurred. After the delivery of the fetal head, how often should this nurse call out the time elapsed?
Every 30 secs
Firm sacral pressure is likely to be most helpful in which situation?
Fetal occiput posterior position
Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, ?2-1. Which one of the following is a correct interpretation of the data?
Fetal presenting part is 1 cm above the ischial spines
A laboring woman just had an amniotomy performed to augment labor. The nurse is aware that the assessment times for which vital signs will be altered?
Maternal temp
What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?
Moderate serosa
